Provider Demographics
NPI:1396793741
Name:HATESOHL, STANLEY MELVIN (MD)
Entity type:Individual
Prefix:
First Name:STANLEY
Middle Name:MELVIN
Last Name:HATESOHL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 21850
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71903-1850
Mailing Address - Country:US
Mailing Address - Phone:870-904-2807
Mailing Address - Fax:501-321-4057
Practice Address - Street 1:410 PONCE DE LEON DR
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS VILLAGE
Practice Address - State:AR
Practice Address - Zip Code:71909-8121
Practice Address - Country:US
Practice Address - Phone:501-922-1700
Practice Address - Fax:501-922-0826
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS21750207Q00000X
ARE-13524207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100206090BMedicaid
KS100206090BMedicaid
KSKA2922005Medicare PIN
KS103370Medicare PIN